The Impact of COVID-19 on Clerkship Preparedness in Third Year Medical Students

doi:10.21203/rs.3.rs-2489508/v1

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Research Article

The Impact of COVID-19 on Clerkship Preparedness in Third Year Medical Students

https://doi.org/10.21203/rs.3.rs-2489508/v1

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Background:

The COVID-19 pandemic presented a unique challenge to medical education, as students were abruptly required to adapt to a remote learning format. Previous studies show a decline in examination performance among medical students during their initial semester of the pandemic, relative to pre-COVID cohorts. The purpose of our study was to investigate whether such negative outcomes affected medical students’ preparedness for clerkship training.

Methods:

Medical students at the Kirk Kerkorian School of Medicine, consisting of both third-year students who completed pre-clinical training amid the COVID-19 pandemic, and fourth-year students from the pre-pandemic cohort, were administered a Qualtrics survey to assess their perceived preparedness for clerkship training. Students’ confidence in key clinical skills were measured, such as taking patient histories, conducting physical exams, and communicating with medical staff. Students rated the relative importance of didactic lectures versus experiential learning for clerkship preparation. Performance on National Board of Medical Examiners shelf examinations were compared.

Results:

There was a significant difference in perception of disadvantage prior to starting clerkships between the COVID-cohort and their pre-COVID counterparts (mean ratings of 4.3/5 vs. 3.4/5). A greater proportion of the COVID cohort deemed experiential learning as more important than didactic lectures (37.5% vs. 62.5%) as opposed to the pre-COVID cohort which considered didactic lectures as more important (53.2% vs. 46.8%). This difference in perception did not translate to a significant difference in academic performance in the six NBME subject exams taken: Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry, and Surgery.

Conclusion:

The implementation of online learning during the COVID-19 pandemic did not have a significant impact on the self-perceived preparedness for clerkship training among medical students. Despite the perception of disadvantage among students who matriculated during the pandemic, overall levels of preparedness do not appear to be affected by the shift to remote instruction. This may be due to a phenomenon the authors deem as the “Grass is Greener,” where individuals perceive that they have missed out on resources that were given to others.

COVID-19

pandemic

medical education

medical students

pre-clinical

clinical rotation

clerkship

clerkship preparedness

online learning

academic performance

Transitioning from Pre-Clerkship to Clerkship Training

Patient history-taking and performing physical exams are foundational skills that first- and second-year medical students learn and practice early in their medical training [1]. Mastery of these skills has allowed physicians to come to proper medical diagnoses for centuries [2]. Taking a detailed patient history and performing a thorough physical exam can significantly impact medical decision making and patient care plans [3]. Although the instruction of fundamental clinical skills to pre-clerkship medical students often employs traditional didactic lectures, mastery of these skills comes from practicing with in-person standardized patients (SPs), guidance from upperclassmen, and supervision by faculty members [4]. The development of innovative simulation techniques constitutes a long-standing objective for medical educators, as enhancement of the quality of these trainings can make a difference in the future of patient care [1, 4]. Once students have had adequate time to practice their skills in a controlled, planned setting, they are prepared to advance into their clerkship training.

In the United States, clerkships typically begin during the third year of medical school [5]. Students rotate through a variety of clinical sites and medical specialties that correspond with the subjects they studied during their preclinical years. This is a time when medical students finally begin to apply what they have learned in the classroom to real-life patients in a clinical setting. By working with the supervising residents and attending physicians, medical students can have face-to-face interactions with real patients and begin to form assessments and treatment plans [6]. Clinical rotations are also a place where students master the ability to work collaboratively with other members of the healthcare team such as surgical technicians, nurses, therapists, and other physicians. During this time, students are frequently being assessed on their clinical knowledge, history-taking, physical exam skills, professionalism, and ability to work well with others [7]. Although clinical knowledge and professionalism are skills that students will need to practice well into their careers, medical students aim to feel prepared to take histories and conduct physical exams prior to beginning clerkships. Furthermore, clinical rotations are crucial in shaping a medical student’s perception of various specialty areas and informing their decision-making process regarding the choice of their post-graduation field of specialization [8]. The clinical setting allows students to begin envisioning what kind of doctor they want to become and is important in shaping their identity as healthcare providers [6].

COVID-19’s Impact on Medical Education

The COVID-19 pandemic forced medical education to rapidly transition to an online training format [9]. Studies show that many medical students were dissatisfied with the quality of their education during this time [10]. Students expressed apprehensions about their proficiency in executing physical examination techniques upon initiation of their clerkship rotation [11]. COVID-19’s impact on medical student academic performance varied amongst medical schools. Despite negative attitudes towards virtual education, some medical schools observed no change in student academic performance on preclinical examinations [12]. However, at other medical schools, first-year medical students who matriculated during the pandemic had worse exam performance than previous cohorts unaffected by the pandemic [11, 13]. Similar variations are seen in performance on the Shelf examinations that students take after their clerkships. Shelf exams are clinical science subject examinations administered by the National Board of Medical Examiners (NBME) [14]. These exams cover core medical student clerkship rotations such as Family Medicine, Internal Medicine, Obstetrics/Gynecology, Pediatrics, Psychiatry, and Surgery. In the literature, there are conflicting results regarding the impact of virtual clerkships on medical students’ performance on standardized examinations. Some studies document lower scores for students who experienced remote rotations during the COVID-19 pandemic in comparison to pre-pandemic counterparts, while other investigations have not revealed any significant variation in exam outcomes [15, 16].

Although previous studies have assessed COVID-19’s impact on medical student academic performance, there is limited data that evaluates students’ perception of their own preparedness when entering clerkships after a virtual preclinical curriculum. This study aims to evaluate how COVID-19 impacted medical student self-perceived preparedness for clerkship rotations. Furthermore, we assessed if cohorts affected by COVID-19 had any difference in Shelf exam scores.

Subjects & Setting

During the year 2020, in light of the COVID-19 pandemic, the class of 2024 at the Kirk Kerkorian School of Medicine (COVID group) were required to commence their medical education in a remote format. As opposed to the traditional method of in-person lectures, examination, and interactions with standardized patients, this inaugural class was forced to adapt to an entirely virtual format for their initial year of study. Prior to COVID-19, classes learned patient interviewing and physical exam skills on standardized patients during their in-person Foundations in Clinical Practice (FCP) course. This course was their opportunity to practice basic physical exam skills prior to performing them on real patients during clerkships. However, due to the pandemic, the class of 2024 was restricted to seeing standardized patients through telemedicine format instead. Although students were still able to perfect their history taking skills through the virtual format, they were unable to learn or practice the important exam skills that went along with synthesizing differential diagnoses. Class of 2023 (Pre-COVID group) was able to attend their FCP class in person, where they were able to practice taking patient histories and performing physical exams as they normally would.

De-identified data was acquired from the school’s evaluation databases through the approved Institutional Review Board (IRB) agreement. Two sets of data were used for this study: Shelf exam performance from both classes of 2023 (pre-COVID group) and 2024 (COVID group) and data from a survey both classes completed. The purpose of this survey was to assess the level of preparedness felt by medical students in regard to their clinical rotations and to evaluate the influence of virtual medical education on this perception.

Survey/Data Collection

A Qualtrics survey was sent to both the pre-COVID and COVID classes regarding their confidence and sense of preparedness in starting their clerkships. The survey asked students to rate their confidence/comfort in performing physical exams, using medical tools, taking histories, and communicating with staff and preceptors. It also asked if they felt disadvantaged due to pandemic related impacts and included an optional text box for students to elaborate on their experiences. In addition, the survey asked them to rate the importance of didactic versus experiential learning in preparing for clerkship using percentages. All other student responses were reported using a 1–5 Likert scale. Responses from the optional text box were reviewed and selected quotes are shown in the Results section. Response rates were 40/60 for the pre-COVID class and 37/58 for the COVID class.

Data Analysis

Academic performance was analyzed for each class to determine if preparedness for clerkships affected exam scores. While most medical students take their shelf exam after each 1–2 month long clerkship, students at Kirk Kerkorian take all six core shelf exams in one week halfway through clerkship year and again at the end of the clerkship year. At the end, the highest scores from the two rounds of exams are used for their final clerkship grades. This encourages students to be constantly reviewing material from all rotations throughout the year. The goal of this is for students to perform well on Step 2 shortly after taking the second round of shelf exams since they have been constantly reviewing all subjects. For this study, Family Medicine, Pediatrics, Internal Medicine, Surgery, Obstetrics and Gynecology, and Psychiatry Shelf exam scores from the first round were averaged for each class. Each respective average was then compared against publicly available national NBME subject examination scores to determine percentile equivalents.

To better understand the differences between the responses provided by the two groups of the survey, we calculated the mean value of each class’s answers per question on a scale of 1–5. Subsequently, an unpaired t-test was performed between both groups for each question to identify any significant differences in their responses.

A comparative table between the two classes were made to better understand and visualize the differences between the responses provided by the two groups on the survey. The result of this analysis is presented in Table 1 below.

Table 1

Survey with Average Responses by Class
Question	Pre-COVID Avg. ± St. Dev. (n = 40)	COVID Avg. ± St. Dev. (n = 37)	p
I felt effectively prepared for clerkships	2.90 ± 0.98	2.78 ± 1.03	0.614
I was comfortable obtaining a complete history of present illness and verbalizing an oral presentation	3.10 ± 1.26	3.35 ± 0.98	0.333
I was confident in performing a physical exam	2.53 ± 1.09	2.30 ± 0.94	0.330
I was confident in use of medical instruments (e.g., sphygmomanometer, stethoscope, etc.)	2.82 ± 1.00	2.86 ± 1.11	0.855
I was confident in my ability to communicate with medical staff	3.55 ± 0.85	3.89 ± 0.70	0.058
I felt comfortable asking for help from my preceptor when I do not understand something	3.75 ± 0.95	4.08 ± 0.80	0.104
I felt comfortable reaching out to my peers for support of any kind (i.e., emotional, assistance with learning gaps) during clerkships	4.20 ± 0.79	4.11 ± 0.74	0.600
Virtual standardized patient encounters were as helpful as in-person standardized patient encounters	2.15 ± 1.08	1.73 ± 1.04	0.087
Please rate the importance of following in preparing for clerkships (Please ensure both numbers add up to 100%) - Didactic learning (lectures, textbook, videos, question banks)	53.18 ± 24.45	37.57 ± 14.89	0.001
Please rate the importance of following in preparing for clerkships (Please ensure both numbers add up to 100%) - Experiential learning (standardized patients, EMT immersion, clinical preparedness courses and programs)	46.83 ± 24.45	62.43 ± 14.89	0.001
I felt disadvantaged prior to LIC due to COVID-19 related impacts on my curriculum	3.35 ± 1.25	4.30 ± 0.91	0.0003

As illustrated in Table 1, there are statistically significant differences in the responses between both classes in terms of the perceived importance of didactic learning in preparation for clerkships (53.175% for pre-COVID versus 37.568% for COVID, p = 0.001), the importance of experiential learning for clerkships (46.825% for pre-COVID versus 62.432 for COVID, p = 0.001), and perceptions of disadvantage prior to clinical rotations due to the impacts of COVID-19 on the curriculum (3.350/5 for pre-COVID versus 4.297 for COVID, p = 0.0003). These were the only survey items found to have distinct responses between the two classes.

We first set out to investigate this distinction in perception of disadvantage between both groups. The pre-COVID group yielded an average 3.35/5 whereas the COVID group provided an average rating of 4.297/5. For visual comparison, the results are depicted in Fig. 1 below, along with a selected qualitative comment from the COVID group to provide additional context.

Lack of patient exposure/ability to engage in preceptorship has had a largely negative impact on my ability to learn skills during my didactic years in medical school. I feel not only behind, but also unprepared going into clerkships. Although the clerkship bootcamp we completed recently was extremely helpful, I'm skeptical that 2 weeks of rushed clinical skills makes up for a year and a half of omitted clinical training.

Given the striking difference in perceptions, we sought to delve further into the relative importance attributed by both groups in the context of clerkship preparedness: experiential learning or didactic learning. Both groups were asked to reflect on which type of knowledge acquisition was more helpful in clerkship preparedness. The mean importance assigned to each type of learning was calculated for both groups, and the results are presented in Figs. 2 and 3.

Both Figs. 2 and 3 primarily indicate the difference in perceived importance for either type of learning amongst groups. The pre-COVID group placed nearly equal importance on didactic learning (53.2%) and experiential learning (46.8%) in preparation for clerkship: nearly one-to-one. On the other hand, the COVID group perceived experiential learning to be on average, more important in preparation, with an average of 62.4%, while perceiving didactic learning to be less important, contributing to 37.6%, or nearly two-to-one.

To provide a quantitative measurement of difference in preparedness between both groups, shelf exam scores were analyzed and compared. Both groups were evaluated against national averages and expressed as percentiles. The results are depicted in Fig. 4.

Figure 4 shows results consistent with prior findings of this paper. Neither group varied significantly amongst each other in either of 6 shelf exams (alpha = 0.05) administered.

COVID-19 challenged medical students in unprecedented ways such as decreased performance on standardized examinations relative to pre-pandemic benchmarks, as well as negative impacts on mental health [17]. These implications leave us pondering whether the damaging effects of COVID-19 further translated to clerkship preparedness and disrupted the future of practicing physicians. Our study demonstrated that the effects of the COVID-19 pandemic had no significant impact on clerkship preparedness in 3rd year medical students at the Kirk Kerkorian School of Medicine. Shelf exam scores did not vary significantly between the COVID and pre-COVID cohorts as well. Furthermore, the COVID cohort had a significantly higher perceived sense of disadvantage compared to the pre-COVID cohort. The COVID cohort rated experiential learning to be more important than didactic lectures in preparation for LIC, while the pre-COVID cohort rated didactic lectures to be more important than experiential learning for LIC preparation.

Perceived sense of disadvantage related to COVID-19

The findings of our study demonstrated significant differences in perceived sense of disadvantage in clerkship preparation in COVID vs pre-COVID cohorts. In the literature, there is evidence of deleterious effects of COVID-19 on medical student wellbeing, resulting in decreased exam performance, inability to study on campus, and paucity of meaningful relationships with their peers and institutional faculty [11]. Most of the clinical preparation in our study’s COVID cohort was in a virtual format with no clinical exposure prior to the start of LIC. Mock patient interviews with standardized patients in this cohort were conducted via an online format which restricted capacity to conduct essential components of a patient interview such as completing a thorough physical exam. In comparison, the pre-COVID cohort experienced in-person clinical preparation. Students in this cohort had the opportunity to conduct in-person interviews and physical exams using standardized patients.

Prior to initiating LIC, the pre-COVID cohort experienced clinical exposure through shadowing residents and the attending physicians at family medicine clinics. In turn, the pre-COVID cohort was able to become accustomed to working with the medical team staff, conversate with real patients, and gain confidence with their plan of care in a medical setting. To our surprise, the pre-COVID cohort did not find pre-clinical, early exposure to the family medicine clinic experience to be significantly useful in preparation of clerkships. In a study of pre-clinical medical students exposed to a pediatric pulmonary clinic, students felt motivated to care for children and felt a sense of team membership even before the start of clerkship [11]. In another study of early-stage medical students with minimal clinical exposure, volunteering at intensive care units during the COVID-19 pandemic significantly fostered resilience and guided career choices. Unfortunately, some participants found the experience difficult to cope with, and felt overwhelmed by this environment [18]. It seems that there are benefits and downfalls of early clinical exposure during the COVID-19 pandemic. Further studies would need to be conducted evaluating pre-clinical exposure during the pandemic.

Didactic lectures vs experiential learning for clerkship preparedness

Didactic learning can be described as textbook education via knowledge obtained from lectures, PBL cases, and web-based medical board exam resources namely, Boards and Beyond, Sketchy, and Pathoma [19]. Experiential learning is more kinesthetic in nature and is knowledge obtained from experiences including gathering a history and physical exam with standardized patients, exploring types of medical equipment, practicing procedures, and working with residents and attending physicians in a hospital or clinic setting. Students of the COVID-cohort rated didactic lectures to be less important when compared to learning through experience in preparation for clinical clerkships. In contrast, the pre-COVID cohort rated didactic lectures to be more important than learning through experience. Both cohorts felt they were unprepared with the use of medical equipment. The COVID-cohort testimonials from our study’s survey seemed to heavily emphasize their disadvantage of missing out on physical exam training due to pandemic related lockdown. In contrast, the majority of the pre-COVID cohort testimonials stated that they were not significantly impacted by COVID-19 in their pre-clinical years. To elaborate, the pre-COVID cohort still had six months of clerkship exposure before they were moved to a modified virtual clerkship, and they instead emphasized that no student is fully prepared for clerkships until they simply begin this transition phase of their training. Some of the pre-COVID cohort students mentioned that one of the most difficult struggles when starting clerkship is navigating the differing EHRs (electronic health record) at hospital and clinic sites. Some clerkship preceptors agree that navigating the EHR may reduce enthusiasm to teach medical students secondary to decreased time interacting with students and they perceive EHR impedes development of student’s critical thinking and clinical integration skills [20]. To add, it has been demonstrated that medical students do not develop self-regulated learning skills during the preclinical stage of their training, and in fact, some skills decrease in both lecture based and problem based learning (PBL) curriculums. Even with implementation of small-group discussions in PBL based medical schools, the quality of implementation in addition to the unique cultural background of students may influence the degree of self-directed learning [21].

NBME shelf exam performance

When comparing shelf exam scores between pre-COVID and COVID cohorts, there were no significant difference between classes in all six subject exams taken: Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry, and Surgery. Currently the clerkship schedules at the Kirk Kerkorian School of Medicine are different from most traditional medical schools. More specifically, each subject of shelf exams are taken in succession within an academic week during the middle of LIC. Shelf exams are then taken again at the end of LIC with a similar schedule to the first round of shelves. Final scores are calculated based on a student’s performance compared to the national NBME average of the previous academic year. Students are assigned one of the following scores for each subject exam: fail, pass, high pass, and honors. Both cohorts maintained higher scores than the national average.

Previous studies report advantages for medical students with the LIC model versus block clerkships such as improved integration within the healthcare team, assuming more roles in patient care, and better understanding of the patient-physician dynamic [22, 23]. The LIC model allows students to consider clinical situations in a holistic manner and incorporate differentials seen across all specialties outside of their current rotation. Research has shown students in LIC, or hybrid models perform better than students undergoing block clerkships in knowledge retrieval, clinical skills, and faculty evaluation [6]. More studies comparing shelf exam scores between medical schools with LIC model versus medical schools with block clerkships would need to be conducted to further elucidate the relationship between clerkship models and exam scores. The authors anticipate the 2nd round of shelf scores at the Kirk Kerkorian School of Medicine at UNLV will also be similar between COVID and pre-COVID cohorts.

Grass is Greener Phenomenon

It has been observed that medical students tend to evaluate the importance of resources based on their level of access to them. This presents a challenge to Medical School Curriculum Committees in determining what content should be included or omitted in the academic curriculum on a yearly basis. The authors of this study propose that the phenomenon of this perspective, referred to as the “Grass Is Greener” phenomenon, is characterized by a general sense of inadequacy, and longing for more favorable outcomes if one had access to the resources that another party possesses. No formal definition of this phenomenon has yet been identified in the literature. The COVID-19 pandemic presented a unique set of challenges for medical students, including disruption in traditional in-person education. Our study illustrates the existence of the “Grass is Greener” phenomenon among medical students, in that feelings of unpreparedness for clerkships were prevalent among students regardless of any limitations imposed by COVID-19 mandates. Despite this, students in the COVID cohort did report missing out on opportunities to develop meaningful relationships with their classmates, but there was no statistically significant difference between this cohort and the pre-COVID cohort in terms of reaching out to peers for emotional support or assistance with learning gaps [11]. Furthermore, this phenomenon may have contributed to the lack of significant difference observed between COVID and pre-COVID cohorts in terms of confidence in performing a physical exam, competence in using medical equipment, and confidence in communicating with medical staff.

The authors of this study propose several strategies to mitigate the negative effects of the “Grass is Greener” phenomenon among medical students. One key method is to improve transparency in communication between medical students and faculty, particularly regarding curriculum changes. The authors suggest that when administration makes modifications to the curriculum without seeking input from medical students, it can leave students feeling confused and uncertain. Another strategy is to ensure continuity of resources for current students by maintaining access to materials and resources used by previous cohorts, such as study guides, notes and other learning tools, even after the assessments or requirements for completions have been done. These resources can be useful as an adjunct to the current curriculum and help students feel more prepared.

Recommendations to improve clerkship preparedness

The transition from didactic training to the LIC component of training can be a challenging process for medical students. Exam scores become replaced in part by subjective evaluations completed by residents and attending physicians and require more critical thinking and execution of clinical skills. Kirk Kerkorian School of Medicine at UNLV has attempted to mitigate the difficult shift by implementing a clerkship bootcamp prior to the start of clinical rotations. To elaborate, the bootcamp program is two weeks in duration and features rotating stations involving application of clinical skills, patient interviewing, and exploring high yield topics taught by residents and attending physicians in each of the six subspecialties: Psychiatry, Family Medicine, Pediatrics, Internal Medicine, Obstetrics and Gynecology, and Surgery. Additionally, for two days out of the two-week training period, our medical students had the opportunity to receive comprehensive instruction on the technical and psychosocial components of reproductive and sexual health exams [24]. A similar clinical skills clerkship program at another institution has demonstrated success in preparing students for LIC. In their model, they implemented a similar three-week course that had three major components: 1. A longitudinal clinical care of a three-generation virtual family assessed with an objective structured clinical examination (OSCE), 2. clinical skills stations 3. professional development exercises [25].

Our study demonstrates that medical students at the Kirk Kerkorian School of Medicine at UNLV who have been affected by the COVID-19 pandemic perceive a significant disadvantage in preparation for clinical clerkships when compared to pre-pandemic students. Furthermore, the COVID cohort viewed experiential learning as more important than didactic lectures whereas the pre-COVID cohort placed greater emphasis on the importance of didactic lectures in preparing for their LIC. This study also highlights the ongoing struggle that Medical School Curriculum Committees face when modifying the academic curriculum, in the form of the “Grass Is Greener” phenomenon. For future direction, there should be more studies investigating the significance of COVID-19’s effects on performance on STEP 2 among COVID and pre-COVID medical students.

UNLV, University of Nevada, Las Vegas

NBME, National Board of Medical Education

SP, standardized patient

FCP, Foundations in Clinical Practice

IRB, Intuitional Review Board

LIC, longitudinal integrated clerkships

OSCE, objective structured clinical examination

EHR, electronic health record

a. Ethics approval and consent to participate

Deidentified data for this study were drawn from institutional databases and all methods were carried out in accordance with relevant guidelines and regulations. All subjects were over the age of 18 years old, and informed consent was obtained from all subjects. All experimental protocols were approved by our institution, Kirk Kerkorian School of Medicine at UNLV and the Institutional Review Board, protocol number 1030906-l.

b. Consent for publication

Not applicable.

c. Availability of data and materials

All data generated or analyzed during this study are included in this published article in the main manuscript and raw data is displayed in the supplementary information files. All information is welcomed and encouraged to be used by other researchers.

d. Competing interests

The authors declare no conflict of interests in the publication of this manuscript. Of note, the authors are 3rd year medical students and are a part of the COVID-cohort being researched at the time of this study. There may be some biases in discussion of differences of opinion between the two groups being studied.

e. Funding

No funding was accepted to assist with preparation of this manuscript. All authors are not involved with any organization or entity with financial or non-financial interest in the subjects or materials discussed above in this manuscript.

f. Authors' contributions

All authors contributed to manuscript work, design, and creation of Qualtrics survey items. Cynthia Lee was the creator of the research project idea, the main allocator of tasks, literature review, and author of the Discussion section. Shaun Andersen was author of the introduction section and conducted a literature review. Deepal Patel managed data collection, analysis of data, and drafted the results section and figures. Genesis Leon assisted with writing the methods section. Dr. Edward Simanton supervised and guided this manuscript from conception. The final manuscript was read and approved by all authors. The data generated and analyzed in this work is included in the published article and will also be made available in a public repository.

g. Acknowledgements

We acknowledge each author for their contributions to this manuscript. The participants for this study are acknowledged for agreeing to be included in this study. We thank the editors for their consideration of our manuscript and their suggestions.

Compliance with Ethical Standards

Informed Consent: Participation is voluntary. Participants are medical are 3^rd and 4^th year medical students from the Kirk Kerkorian School of Medicine at UNLV who consented to study at the start of the survey they completed.

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No competing interests reported.

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The Impact of COVID-19 on Clerkship Preparedness in Third Year Medical Students

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Abstract

Figures

Background

Transitioning from Pre-Clerkship to Clerkship Training

COVID-19’s Impact on Medical Education

Methods

Subjects & Setting

Survey/Data Collection

Data Analysis

Results

Discussion

Perceived sense of disadvantage related to COVID-19

Didactic lectures vs experiential learning for clerkship preparedness

NBME shelf exam performance

Grass is Greener Phenomenon

Recommendations to improve clerkship preparedness

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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Version 1